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Health and social care inspectorate body the Care Quality Commission said they were "appalled" by the Serious Case Review into the deaths of five residents of Orchard View care home, and admitted they did not act quickly enough.

They were criticised by the coroners report into the death for giving the home a "good" rating a year before shutting it down.

Chief Inspector Andrea Sutcliffe said the blame for the "sub-optimal" care lay with those working in the home.

I was appalled by the descriptions of what had happened at Orchid View. Today’s Serious Case Review once again shows what a truly tragic situation this was and my thoughts remain with the people who suffered such awful care and with their families.

The Serious Case Review shows the primary responsibility for these failings rests with the people providing services at Orchid View, together with their owners Southern Cross.

Ms Sutcliffe admitted the Care Quality Commission missed early warning signs, and did not act quickly or strongly enough. She said:

At CQC we made a commitment to take a long, hard look at our role, make sure lessons were learned - and most importantly - turn those lessons into action.

We know from our own review that we did not fulfil our purpose of making sure Orchid View provided services to people that were safe, compassionate and high quality.

"A number of the concerns identified in the recent past with hospital services in the NHS have been echoed at Orchid View and it is right that the scrutiny and demands for improvement in the NHS are also expected from the independent sector.

"As a result of the concerns about the NHS there have been recent government consultations relating to a duty of candour, the fit and proper person test, and a new offence of wilful neglect where people have mental capacity.

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Expert lawyers and families whose loved ones endured ‘institutionalised abuse’ at a Sussex care home welcomed the Serious Case Review published today as a step forward for the care industry but warned that its recommendations must now be delivered to prevent further widespread abuse.

West Sussex Adult Safeguarding Board commissioned the review after an inquest into the deaths of 19 residents at Orchid View Care home in Copthorne but some of the families of those who died say they are frustrated at a continued lack of accountability for the neglect their loved ones suffered.

The home closed in October 2011 and re-opened under new management in February 2012 as Francis Court but lawyers are concerned that in October last year the new home was also criticised after a Care Quality Commission (CQC) inspection.

We still believe the horrific scale of neglect warrants a completely independent inquiry which would take into account this Review as well as pulling together all the organisations involved in safeguarding care to provide a true blueprint for change in reforming the whole care industry – this must be the lasting legacy of the Orchid View scandal."

– Laura Barlow, lawyer at Irwin Mitchell representing the families

The key question we still have is why Orchid View could appear from the outside to be one of the best care homes in the country, when in fact it was clearly one of the worst. There needs to be a much better system for sharing information about care home standards and about the people who are working in and running them. It is really important to us that the recommendations revealed today become reality as soon as possible so that care homes can be improved across the country.”

Undertaking this Serious Case Review into what happened and how to guard against future failings was complex. It was not designed to place blame on any organisation or individual. However, it does not shy away from criticising organisations that could and should have done better.

The report’s recommendations are intended to promote service quality and improved information to the public and stronger accountability drawing on the practice, management and scrutiny of Orchid View to improve such services into the future."

We welcome this report and its recommendations. There is nothing more important than looking after the most vulnerable people in our society and in this respect Southern Cross Healthcare has been judged to have failed. Statutory agencies such as West Sussex County Council had no choice but to take action to investigate and ultimately move people from the home to protect them.

Nothing will help ease the pain of the families who were affected by these terrible events and who lost loved ones. I want to offer them my condolences and assure them that we will act on the recommendations..."

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A Serious Case Review will be published today after five elderly people died after suffering neglect at Orchid View care home in Sussex. It's been labelled "Britain's worst care home".

Following a five-week inquest last October, coroner Penelope Schofield heavily criticised the quality of care at the Southern Cross-run home in Copthorne. Failings included a lack of respect for the dignity of residents, poor nutrition and hydration and mismanagement of medication.

Ms Schofield said at the inquest's conclusion, "There was institutionalised abuse throughout the home...Those who did nothing or turned a blind eye should be ashamed. It is disgraceful that this home was allowed to be run in the way it did and run for nearly two years."

The inquest looked at the deaths of 19 pensioners at Orchid View after whistleblower Lisa Martin contacted police to raise concerns. The coroner ruled all of these residents suffered "sub-optimal" care but five of the residents died from natural causes "which had been attributed to by neglect".

The home was shut down in late 2011 after an investigation by the CQC.